Thursday, May 4, 2017

Improving Birth Outcomes in Louisiana

Author:Rebekah E. Gee, MD, Secretary, Louisiana Department of Health

In an effort to create a generation of healthier women and children in
Louisiana, our team at the Louisiana Department of Health initiated the
Louisiana Birth Outcomes quality effort in 2010. The team, that included staff
from Medicaid, the Office of Public Health, the Louisiana Perinatal Commission
and other medical experts, began with the goal of eliminating medically
unnecessary or elective deliveries prior to 39 weeks gestation as one of its
major strategies. Specifically, this included cesarean deliveries or inducing labor
through medication.

According to maternal
health experts, elective deliveries before 39 weeks of gestation poses both
short-term and long-term health risks for the newborn as there are key
developmental processes that occur in the last several weeks of a full-term
pregnancy. Early elective deliveries are also more expensive than standard
deliveries.

In addition, we sought to create a culture of continuous quality
improvement in hospitals in Louisiana that delivered babies, reduce costs and,
ultimately, reduce the number of poor birth outcomes as measured by preterm
birth, low and very low birth weight, C-section rate and infant mortality.

With the Louisiana Medicaid program paying for almost 70 percent of
births in Louisiana (the second highest Medicaid birth rate in the nation), we
had a great opportunity to make improvements.

For our effort to be successful, we recognized that we could not simply
use the force of State government to effect this change. Instead, we identified
people and teams from throughout the state to participate. The teams
represented community partners, health care consumers, advocates, public health
professionals, clinicians, hospital administrators and insurers. Including
professionals from each of these disciplines allowed us to take into account
the complex interplay of social, behavioral, biological and genetic factors
that influence birthing decisions and outcomes.

By July 2011, 20 birthing hospitals in Louisiana had pledged to
participate in this voluntary initiative. By January 2012, all of the state’s hospitals
where babies are delivered had pledged to work toward that goal.

The 39-week standard is not a new one. For almost three decades, the
American College of Obstetricians and Gynecologists and the American Academy of
Pediatrics have had in place a standard requiring 39 completed weeks gestation
prior to elective delivery such as a cesarean delivery or medically inducing labor.

To achieve optimal birth outcomes, hospitals must implement
evidence-based best practices. While poor birth outcomes are well-documented in
Louisiana, performance measurement systems to monitor the success of
initiatives to improve birth outcomes are often not available outside of
hospital-level reporting. Now that birthing hospitals were implementing the
39-week initiative, we needed a system to monitor improvements in birth
outcomes without burdening the hospitals.

The Birth
Outcomes Initiative leadership partnered with the Louisiana Hospital
Association; various LDH programs including the Bureau of Family Health, Office
of Vital Records and Louisiana Medicaid; private physicians and health care quality
experts to find a solution.

Through this partnership, it was decided to also make changes to
Louisiana birth certificates to include reasons for deliveries prior to 39 weeks.

With several other researchers, I recently co-authored a study,
published by the Journal of Maternal and Child Health, on the effectiveness of
this birth certificate initiative. The study reviewed more than 4,300 births in
Louisiana’s largest maternity hospital. Our study found that the medical reason
for early delivery listed on the birth certificate matched the reason recorded
by the hospital 99.8% of the time.

The most common reasons listed for early delivery were spontaneous
active labor, gestational hypertensive disorders, gestational diabetes and
premature rupture of membranes. The information now contained in the birth
certificate shows the hospital has all but eliminated non-medically necessary
preterm births. The full study, “Public Health Data in Action: An Analysis of
Using Louisiana Vital Statistics for Quality Improvement and Payment Reform,” can
be found here.

The 39-week initiative has resulted in an 85 percent decrease in
elective preterm births, a corresponding 10 percent decrease in NICU admission,
and has proven to reduce early elective deliveries without any medical
indications.